Pediatric Stem Cell Transplant Unit Research Articles

The Influencing Factors for Stem Cell Apheresis in Pediatric Cancer Patients

Objective: Pediatric cancer patients comprise a fragile patient group regarding age and intensive therapy. It is known that factors like apheresis machine, characteristics of patients, primary disease, and cellular parameters before the process impact the efficacy of stem cell apheresis. In this study, we aim to evaluate the characteristic features of stem cell apheresis and the influencing factors of the process. Patients and Methods: This study involves 42 patients who received a total of 88 aphereses, between August 2012-March 2021in our pediatric stem cell transplantation unit. All of the patients received chemotherapy and GCSF for mobilization. The patients received plerixafor in case of unsuccessful mobilization. Results: For most of the patients (n= 23, 55%), targeted cell numbers could be reached on the second day of apheresis. Especially the patients with neuroblastoma and lymphoma need to have more than one apheresis. Our results indicate that median MNC and CD 34 + cell counts before the apheresis were significantly associated with successful apheresis (p< 0.01 and p= 0.03 respectively). Regarding the influence of primary disease, we showed that successful apheresis was less in neuroblastoma and lymphoma compared to other pediatric cancers (p= 0.01). We reported successful apheresis with plerixafor for six patients who had unsuccessful apheresis before. Conclusion: In this study, it is shown that median MNC counts before apheresis, median CD 34 + cell counts before apheresis, and primary disease are influencing factors for successful apheresis. This study indicates that plerixafor may enhance the apheresis efficacy even in unsuccessful apheresis attempts with standard mobilization protocol. Identifying the influencing factors on apheresis for such a fragile patient population may help the procedure to be more efficient and safe for the children.

Exercise is Medicine: Implementing a New Initiative to Increase Patients' Activity and Functional Mobility in Pediatric Stem-Cell Transplant Unit.

Patients undergoing stem-cell transplants endure prolonged hospitalizations and aggressive medical treatments. This combination can quickly evolve into loss of functional strength and physical debilitation. We aimed to promote independent patient activity during hospitalizations, to improve compliance with prescribed physical therapy (PT) sessions, and to focus those sessions on resistance and endurance exercises. We used the Institute for Healthcare Improvement Model of Improvement as our quality improvement (QI) framework, and we implemented an initiative called Exercise is Medicine. The initiative included three key components: (1) educating staff and caregivers about the importance of early ambulation, (2) incorporating the Miles in Motion (MiM) program to encourage patients' daily activity, and (3) eliminating barriers to allow for higher completion rates of prescribed PT sessions. Data were collected for the completion rate of PT sessions, rate of high-frequency PT sessions, participation in the MiM program, and 1-minute sit-to-stand test scores on admission and discharge. Before intervention, 42% of patients required high-frequency PT because of significant debilitation, which decreased to 17% after intervention. The completion rate of PT sessions increased from 71% to 87%. By discharge, 79% of patients improved their 1-minute sit-to-stand test scores and 21% returned to baseline score, indicating stable or improved functional strength, and 92% of patients participated in MiM. The Exercise is Medicine initiative facilitated positive changes with patients showing stable or improved functional strength and endurance and increased participation in independent activity during inpatient stays.

A qualitative study of pediatric nurses' perception of factors affecting negotiation of care in a pediatric stem cell transplant unit.

The adoption of a 'family-centered-care' philosophy is essential for the care process and its negotiation. A better understanding of nurses' perception of factors that affect the process of negotiation could allow us to better address future interventions and to improve FCC. The purpose of our study was to investigate pediatric nurses' perception of factors that affect the process of negotiation of care with Stem Cell Transplantation pediatric patients and their parents. A qualitative research design with in-depth interviews was chosen. Sixteen interviews (16 nurses) were audio recorded and transcribed verbatim. Two researchers conducted independently a thematic analysis of the verbatim transcripts of the interviews. Four themes emerged from the data as factors that affect the process of negotiation: (a) communication, (b) personal factors (c) specificity, and (d) organization. These themes represent interesting points for future improvement interventions. Negotiation in the Stem Cell Transplant setting would deserve further research, with special focus on children' and parents' perception of factors affecting this important aspect. Furthermore, in the future, negotiation guidelines could be validated and implemented effectively and an already validated tool could be used to document the negotiation process in the Stem Cell Transplant setting.

Retrospective Evaluation of Relationship Between Iron Overload and Transplantation Complications in Pediatric Patient Who Underwent Allogeneic Stem Cell Transplantation Due to Acute Leukemia and Myelodysplastic Syndrome.

Hematopoietic stem cell transplantation (HSCT) is a curative therapy option for hematologic malignancies. Iron overload is common in this patient group and can impact short-term and long-term nonrelapse mortality. Retrospective observational cohort study. To evaluate the effect of iron load on early and late HSCT outcomes in patients with acute leukemia and myelodysplasia to assess the necessity of reducing iron load. Sixty patients who underwent HSCT in pediatric stem cell transplantation unit between 2000 and 2012 were evaluated retrospectively. The patients were divided into those with pretransplantation serum ferritin levels above and below the median value of 1299 ng/mL. Forty-two (70%) of the patients were male, mean ages of the low and high ferritin groups were 85.43±9.42 and 118.56±10.04 months, respectively. Acute graft-versus-host disease (GVHD) within the first 100 days and acute liver GVHD were significantly more common in the high ferritin group (P<0.011 for both). Ferritin level was not associated with rates of engraftment syndrome, veno-occlusive disease, early/late infection, relapse, or overall and disease-free survival. In our study, significant result especially in terms of acute liver GVHD, was important to emphasize the need to be more careful in terms of acute liver GVHD risk in early liver pathologies in patients with high levels of ferritin after transplantation. In future large studies may be helpful to explain the relationship between acute liver GVHD and high ferritin levels.

Effect of An Evidence-Based Nursing Intervention on the Diagnosis of Oral Mucositis in the Pediatric Stem Cell Transplant Unit

Objective:This quasi-experimental, single-group study with a pre- and post-repeated measures design was carried out at the Pediatric Stem Cell Transplant Unit of a University Hospital. The study was aimed at investigating the effect of an evidence-based nursing intervention program, held for nurses providing care for pediatric stem cell transplant patients, on their skills in diagnosing oral mucositis (OM).Methods:Before training, data were collected from all the nurses using a sociodemographic characteristics questionnaire. Six patients who were admitted to the clinic and started chemotherapy (CT) were followed up for a maximum of 1 month during their hospitalization to find whether the diagnosis of OM was performed. During the intervention stage, the researcher provided nurses with training on the importance of the use of evidence-based research results in the clinic, including evidence regarding OM. After the training, the records of six patients who were admitted to the clinic and started CT were tracked for up to 1 month during their hospitalization to find whether the diagnosis of OM was performed.Results:At the end of the study, the rate of OM diagnosis was performed by nurses, which was 2.8% before the program and increased to 8.7% after the program. The difference between the percentages of performing OM diagnosis by the nurses before and after the program was 5.9%, which was considered statistically significant (χ2 = 11.004, P < 0.01). The postprogram rate of diagnosis of OM was 3.12 times higher (212% increase) than the preprogram rate (P < 0.01).Conclusions:One of the most important recommendations of the present study is to provide regular and continuous training sessions for nurses to improve and update their knowledge on oral care. It is also concluded that the establishment of oral diagnosis as a follow-up parameter, similar to vital signs in the clinic, will enable nurses to improve their skills in performing daily diagnosis and keeping proper records of the patients’ outcomes.

410 - Infusion Reactions Related to Antithymocyte Globulin Administration: Retrospective Study in a Pediatric Stem Cell Transplantation Unit

410 - Infusion Reactions Related to Antithymocyte Globulin Administration: Retrospective Study in a Pediatric Stem Cell Transplantation Unit

562 - Drug Shortages in a Pediatric Stem Cell Transplantation Unit: A 5-Year Analysis of Incidences and Solutions

562 - Drug Shortages in a Pediatric Stem Cell Transplantation Unit: A 5-Year Analysis of Incidences and Solutions

Accuracy of Bedside Paediatric Early Warning System (BedsidePEWS) in a Pediatric Stem Cell Transplant Unit.

Hospital mortality in children who undergo stem cell transplant (SCT) is high. Early warning scores aim at identifying deteriorating patients and at preventing adverse outcomes. The bedside pediatric early warning system (BedsidePEWS) is a pediatric early warning score based on 7 clinical indicators, ranging from 0 (all indicators within normal ranges for age) to 26. The aim of this case-control study was to assess the performance of BedsidePEWS in identifying clinical deterioration events among children admitted to an SCT unit. Cases were defined as clinical deterioration events; controls were all the other patients hospitalized on the same ward at the time of case occurrence. BedsidePEWS was retrospectively measured at 4-hour intervals in cases and controls 24 hours before an event (T4-T24). We studied 19 cases and 80 controls. The score significantly increased in cases from a median of 4 at T24 to a median of 14 at T4. The proportion of correctly classified cases and controls was >90% since T8. The area under the curve receiver operating characteristic was 0.9. BedsidePEWS is an accurate screening tool to predict clinical deterioration in SCT patients.

The Cell Loss after Thawing in Cord Blood Units

Umbilical cord blood (CB) are increasingly used for allogeneic transplantation as an alternative source to bone marrow or peripheral stem cell for patients who lack a human leucocyte antigen (HLA)-matched donor. Cell dose is one of the main determinant factor for selection of the unit and it has been shown to correlate with time and probability of engraftment. Cell doses available for selection of the unit are the ones evaluated before cryopreservation. Processing of the graft either with cryopreservation and/or thawing inevitably lead to cell loss but the data showing to what extent is very limited although this has great importance especially for the units with critical cell counts. To evaluate the extent of the cell loss after thawing and the effect of preservation duration on cell loss and the viability, we retrospectively analyzed our single center experience in a cohort of patients receivingunrelated CBT.Sixty cord blood units used for unrelated CBT in fifty-eight patients in our Pediatric Stem Cell Transplantation Unit were included in the study. One of the patient was transplanted with double cord blood unit and one had recurrent CBT because of previous graft failure.Median number of declared TNC per kilogram of recipient body weight was 16x107/kg (range: 3,16-59,1). After thawing the median TNC dose decreased to 11,1x107/kg (range:1,5-34), with median cell viability at 80%. The median TNC recovery was found as 70%. Median CD 34+ cell count declared by the banks per kilogram body weight of recipient was 6,0x105/kg (range: 0,5-37). The CD 34 cell count of one of the units used in a patient having double cord blood infusion was not available. The CD34 cell count of the other complementary unit was 0,48x105/kg. Since the total cell counts received bu the recipient was given, the CD34 cell count of the patient having double CB infusion was not included in statistical analysis. The median postthawed CD 34 cell count was 3,4 x105/kg (range: 0-21)and median CD34 cell recovery was %58.The storage duration of the CB units in liquid nitrogen was available for 59 units and that was 52±30 months (range:3-130 months). Correlation analysis did not show any significant correlation between CB unit storage duration and viability (r=-0,2 p=0.07). Also any correlation between storage time and also TNC and CD34 cell recovery were not identified.Our study indicated that approximately 30% of cell loss is expectable in cord blood transplantation because of either cryopreservation or thawing. It should be kept in mind while assessing acceptibility of cord blood units with limited cell counts DisclosuresNo relevant conflicts of interest to declare.

Utilizing the town meeting forum to involve caregivers of pediatric patients undergoing bone marrow and stem cell transplantation

Caregivers of children undergoing bone marrow and stem cell transplantation face unique and significant challenges. The average length of stay for patients on the Duke Pediatric Stem Cell Transplantation Unit is often several months. Caregivers are required to leave their homes and extended families in hope of a life-saving transplantation for their child. They enter a strange environment over which they have very little control. Parents often report feelings of “helplessness” and “being at the mercy of others” during this difficult period of time.

Allogeneic bone marrow transplantation for juvenile myelomonocytic leukemia: a single center experience of 23 patients

Summary:Juvenile myelomonocytic leukemia (JMML) is a childhood leukemia for which allogeneic BMT is the only curative therapy. At our pediatric stem cell transplantation unit, we performed 26 BMTs in 23 children (age 0.5–12.7 years). Conditioning was CY/TBI based (1980–1996, n=14) or BU/CY/melphalan based (1996–2001, n=9). Donors were HLA-identical siblings (n=11), unrelated volunteers (n=9) or mismatched family members (n=3). A total of 10 patients survive in CR (median follow-up 6.8 years, range 3.1–22.2 years). Relapse or persistent disease was observed in eight and two patients, respectively. Nine of these patients died, one achieved a second remission following acute nonlymphatic leukemia chemotherapy (duration to date 5.3 years). Transplant-related mortality occurred in four patients. Overall survival at 5 and 10 years was 43.5%. Using T-cell-depleted, one-antigen mismatched unrelated donors was the only significant adverse factor associated with relapse in multivariate analysis (P=0.039, hazard ratio 4.9). Together with a trend towards less relapse in patients with graft-versus-host-disease and in patients transplanted with matched unrelated donors, this suggests a graft-versus-leukemia effect of allogeneic BMT in JMML.

Assessment of Bioaerosol Reduction Methods in Stem Cell Transplant Units at a University Hospital

Severely immunocompromised patients, such as those who have undergone stem cell transplantation, must be housed in a protective environment to reduce the risk of acquiring health care-associated fungal infections. This 11-month study was conducted at Duke University Hospital to evaluate the efficacy of the existing engineering controls (EC) for two such protective units: the pediatric stem cell transplant unit (PTU) and the adult stem cell transplant unit (ATU). In addition, a standard intensive care unit (ICU) was included as a “control” nursing unit. The engineering controls evaluated during the study included high efficiency particulate air (HEPA) filtration of supply air, supplemental HEPA refiltration, air change rates, directional airflow in patient rooms, positive pressure gradient (directional air flows) throughout the unit, and an interlocked airlock. Significant performance differences were identified when the bioaerosol sampling data from the three units were compared. These differences were related to the presence and performance of the evaluated EC. The concentration of airborne fungal spores in the PTU, which was equipped with all the evaluated EC performing at design specification, was less than both the ATU (p = 0.0007) and the ICU (p = 0.001). This suggests that utilizing an appropriate combination of engineering control measures is an effective means of controlling airborne bioburden. This study also provides evidence of the importance of supplemental HEPA refiltration and the establishment and maintenance of a strong positive pressure gradient (>2.5 Pascals).

Continuous platelet drip: a unique approach in the treatment of severe/refractory thrombocytopenia in the pediatric stem cell transplant population

Thrombocytopenia is an expected complication of marrow ablative therapy. Platelets are the last hematopoietic cell to ablate and the last to recover after conditioning for tranplant. Bleeding remains a significant cause of morbidity and morality in the immunosuppressed patients. Patients undergoing stem cell transplantation are at greater risk due to the prolonged duration and severe nature of the aplastic period. Therefore, long term supportive care via platelet transfusion is a common and expected therapy in this patient population. As a result of therapy, many patients become refractory to platelet transfusions. These patients may require more intensive measures that include frequent platelet transfusions or continuous platelet drips to prevent complications from bleeding. To further complicate matters, many patients undergoing transplantation are often fluid sensitive and at times fluid restricted. The added volume of multiple platelet transfusions can pose additional risk to an already fragile patient. The use of continuous platelet drips has proven to be an effective way to treat severe/refractory thrombocytopenia and minimize the additional fluid volume. The Duke Pediatric Stem Cell Transplant Unit utilizes continuous platelet drips for select patients. Patients receiving this therapy must meet specific criteria including thrombocytopenia that is refractory despite twice-daily platelet tranfusions and a high risk for bleeding. The purpose of this abstract is to describe the indications, risks, benefits, and nursing challenges associated with continuous platelet drips.

Surviving the shortage: How we increased retention and recruitment by increasing morale on Duke's Pediatric Stem Cell Transplant Unit

Surviving the shortage: How we increased retention and recruitment by increasing morale on Duke's Pediatric Stem Cell Transplant Unit

Surviving the Shortage: How We Increased Retention and Recruitment by Increasing Morale on Duke's Pediatric Stem Cell Transplant Unit

Surviving the Shortage: How We Increased Retention and Recruitment by Increasing Morale on Duke's Pediatric Stem Cell Transplant Unit